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Restaging oesophageal cancer after neoadjuvant therapy with 18F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery

  • Oncology
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

It is unknown whether restaging oesophageal cancer after neoadjuvant therapy with positron emission tomography-computed tomography (PET-CT) is more sensitive than contrast-enhanced CT for disease progression. We aimed to determine this and stratify risk.

Methods

This was a retrospective study of patients staged before neoadjuvant chemotherapy (NAC) by 18F-FDG PET-CT and restaged with CT or PET-CT in a single centre (2006-2014).

Results

Three hundred and eighty-three patients were restaged (103 CT, 280 PET-CT). Incurable disease was detected by CT in 3 (2.91 %) and PET-CT in 17 (6.07 %). Despite restaging unsuspected incurable disease was encountered at surgery in 34/336 patients (10.1 %). PET-CT was more sensitive than CT (p = 0.005, McNemar’s test). A new classification of FDG-avid nodal stage (mN) before NAC (plus tumour FDG-avid length) predicted subsequent progression, independent of conventional nodal stage. The presence of FDG-avid nodes after NAC and an impassable tumour stratified risk of incurable disease at surgery into high (75.0 %; both risk factors), medium (22.4 %; either), and low risk (3.87 %; neither) groups (p < 0.001). Decision theory supported restaging PET-CT.

Conclusions

PET-CT is more sensitive than CT for detecting interval progression; however, it is insufficient in at least higher risk patients. mN stage and response (mNR) plus primary tumour characteristics can stratify this risk simply.

Key Points

• Restaging 18 F-FDG-PET-CT after neoadjuvant chemotherapy identifies metastases in 6 % of patients

• Restaging 18 F-FDG-PET-CT is more sensitive than CT for detecting interval progression

• Despite this, at surgery 10 % of patients had unsuspected incurable disease

• New concepts (FDG-avid nodal stage and response) plus tumour impassability stratify risk

• Higher risk (if not all) patients may benefit from additional restaging modalities

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Acknowledgements

The authors thank Rachael Styles for her assistance in data collection. JMF had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

The scientific guarantor of this publication is Mr. John M Findlay. The authors of this manuscript declare relationships with the following companies: MRM has the following roles to disclose: Advisory/Consulting Role (payment to the individual) Amgen, BMS, GSK, Merck, Millennium and Roche. Research Funding (payment to the institution) from Amgen, AZ, BMS, Clovis, Eisai, GSK, Immunocore, Johnson & Johnson, Merck, Millennium, Novartis, Pfizer, Roche and Vertex. FVG is a paid consultant to Alliance Medical. The remaining authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors has significant statistical expertise. Institutional Review Board approval was obtained. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, diagnostic or prognostic study performed at one institution.

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Authors and Affiliations

  1. Oxford OesophagoGastric Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK

    John M Findlay, Richard S Gillies, Greg E Jones, Sara di Carlo & Nicholas D Maynard

  2. NIHR Oxford Biomedical Research Centre, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK

    John M Findlay & Mark R Middleton

  3. Department of Nuclear Medicine, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK

    James M Franklin, Eugene J Teoh, Fergus V Gleeson & Kevin M Bradley

  4. Royal Berkshire Hospital, Craven Road, Reading, RG1 5AN, UK

    Greg E Jones

  5. Queen’s Medical Centre, Derby Road, Nottingham, NG7 2UH, UK

    Sara di Carlo

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  1. John M Findlay
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Correspondence to John M Findlay.

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Findlay, J.M., Gillies, R.S., Franklin, J.M. et al. Restaging oesophageal cancer after neoadjuvant therapy with 18F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery. Eur Radiol 26, 3519–3533 (2016). https://doi.org/10.1007/s00330-016-4227-4

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  • DOI: https://doi.org/10.1007/s00330-016-4227-4

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